OBG

03/01/2019

Heavy and irregular Menstruation

Heavy and irregular Menstruation

INTRODUCTION

In the past, large family size, prolonged breastfeeding and reduced life expectancy limited the number of menstrual cycles experienced by women. Currently, women may experience more than 400 menstrual periods during reproductive life, and problems related to menstruation are a common cause of consultation to gynecologists. Abnormal bleeding can be a consequence of pelvic pathology, including malignant disease, but the majority of women who present with bleeding problems have no underlying abnormality. Indeed, a significant proportion of women who complain of heavy bleeding are found to have normal menstrual loss if this is measured objectively. Concerns about the widespread use of hysterectomy in this situation have led to a well-developed evidence base for medical management. This , together with less invasive surgical methods, has increased the range of options available for the relief of menstrual bleeding problems.

DEFINITIONS

Menorrhagia is heavy, regular blood loss occurring over several consecutive cycles. The accepted definition of heavy blood loss based on objective measurement is more than 80 ml per period, although a loss of 60 ml or more is associated with the development of anaemia. The term menorrhagia excludes inter menstrual or postcoital bleeding and should be distinguished from irregular bleeding or sudden changes in bold loss, all of which may be associated with underlying pathology . Regular heavy bleeding without an identified local cause is also known as dysfunctional uterine bleeding (DUB). It is useful to distinguish between ovulatory dysfunctional bleeding (regular cyclist) and anovulatory dysfunctional bleeding. The latter usually occurs at the extremes of reproductive life and results in prolonged, irregular, sometimes heavy bleeding for which different management strategies are appropriate.

INCIDENCE

It has been estimated that 5 per cent of women aged between 30 and 49 report with excessive menstrual bleeding in a year. Excessive menstrual bleeding accounts for 12 per cent of gynecology referrals .

AETIOLOGY

The aetiology depends on the pattern of abnormal bleeding and is also influenced by the age of the patient and other factors.

Menorrhagia

Fibroids are the commonest structural cause of menorrhagia . Heavy bleeding associated with fibroids is often painless; painful heavy periods may be secondary to adenomyosis . Coagulation disorders are a rare cause of menorrhagia and usually present in young women in whom there is likely to be a history of other bleeding problems.

In cases of objectively confirmed menorrhagia (> 60mL blood loss per period), abnormalities in the local control of menstruation have been described. These include abnormal levels of the vasoconstrictors. Abnormalities of the local coagulation mechanisms have also been described.

Heavy irregular bleeding

Anovulatory menstrual cycles are common following the menarche and in the lead up to the menopause, and abnormal bleeding is a consequence of prolonged stimulation of the endometrium by oestrogen, unopposed by progesterone. Bleeding is painless and in teenagers is usually limited to a few cycles. In the peri menopause, various histological abnormalities may occur, ranging from simple hyperplasia that is reversible by progestogen to severe atypical and malignancy. Anovulatory dysfunctional bleeding is also a well-recognized consequence of polycystic ovary syndrome. Irregular bleeding may be associated with other endocrine disorders, particularly thyroid disease, although the underlying mechanism is unclear.

Intermenstrual and postcoital bleeding

These two frequently co-exist and may have a common etiology. While serious pathology, in particular cervical carcinoma, may be present, most cases are due to benign cause and often no cause can be found. Bleeding at mid-cycle is secondary to the mid-cycle oestradiol surge and is regarded as physiological. In young women, Chlamydia infection may present with Intermenstrual or postcoital bleeding. On visualization of the cervix, benign cervical conditions such as polyps may be present.

MANAGEMENT

Decisions regarding both investigation and treatment are influenced by a number of factors, which include the age and reproductive status of the individual women, the pattern and severity of her symptoms and the degree of disruption that she experiences. Many women may simply seek reassurance. A detailed and accurate history is assessing in eliciting any relevant medical problems and in assessing the impact of the problem for each individual woman.

Investigations

Menorrhagia

Abdominal and bimanual pelvic examinations should be performed, together with a cervical smear if due and a full blood count. If examination is normal , no additional investigations are required prior to the initiation of therapy . If the uterus is felt to be enlarged (>10-12 week size), an ultrasound scan will be helpful in delineating fibroids or excluding other causes of a pelvic mass. If coagulation disorders are suspected, particularly in young women, a clotting screen should be carried out . Where medical treatment has failed , or where there are specific risk factors for endometrial cancer (obesity, tamoxifen therapy, polycystic ovary syndrome), more detailed evaluation of the endometrial cavity should be carried out.

Prolonged or irregular bleeding

Most cases will be associated with the peri menopause. Endocrine investigation is unnecessary unless there is clinical suspicion of thyroid disease or premature ovarian failure .

Endometrial assessment should be clinic based and includes endometrial sampling in combination with either transvaginal ultrasound (TVS) or outpatient hysteroscopy . Hysteroscopy is regarded as a gold standard for endometrial evaluation when used in combination with biopsy.

Intermenstrual and postcoital bleeding

Careful examination of the cervix is essential, and any suspicious findings are an indication for colposcopy. In young women, Chlamydia infection should be excluded Where the bleeding is confined to mid-cycle, further investigation is not required. TVS is a simpler and less invasive primary investigation in the detection of endometrial polyps or submusosal fibroids . Although the incidence of polyps and endometrial abnormalities rises with increasing age, sub mucosal fibroids are more common in younger women.

MEDICAL MANAGEMENT

Non-hormonal therapy

For women menorrhagia requiring non-hormonal treatment, antifibrinolytics (e.g. Tranexamic acid) or non steroidal anti – inflammatory drugs (NSAIDs; e. g. mefenamic acid) are first-line drugs . Both are used only during menstruation and are generally well tolerated. As antifibrinolytics and NSAIDs have different mechanisms of action in menorrhagia, they may be effective when used in combination .

Combined oral contraceptive pill

For women requiring contraception or for whom hormonal agents are acceptable, combined oral contraceptive pill (COCP) preparations are effective in reducing menstrual bleeding, controlling cycle irregularities and relieving menstrual pain.

Progestogen

Cyclical progestogen are traditionally the drug of first choice for the control of anovulatory dysfunctional bleeding.

Progestogen-releasing intrauterine system

The levonorgestrel – releasing intrauterine system (LNG-IUS) is licensed in many countries for the relief of menorrhagia. The continuous exposure of the endometrial to progestogen induces progressive atrophy, with reduction of menstrual bleeding by more than 80 per cent after 3-6 months and more than 90 per cent at 12 months .

Spontaneous expulsion occurs in 3-6 per cent of women and there is an initial incidence of breakthrough bleeding as high as 25-55 per cent in the early months. Progestogen side effects of bloating , breast tenderness, mood swings and acne may occur, and careful counseling is essential prior to insertion .

Other medical therapies

Second-line drugs are available for the control of severe bleeding when simpler measures have failed and, as they reliably induce amenorrhea, are useful in the management of severe anemia or in the presence of medical disorders when surgery may be contraindicated. Gonadotropins releasing hormone (Gnrh) agonists induce a hypogonadal state via their central action. While effective, these approaches are usually limited to short-term use because of their side effects .

SURGICAL MANAGEMENT

While medical treatment should always be used as first-line therapy for menorrhagia , limitations in efficacy and side effects will result in many women seeking a surgical solution for their problem. Traditionally, hysterectomy has been the principal surgical management for menstrual disorders. Hysteroscopy methods of endometrial ablation are now well established as day case or outpatient procedures, and recent developments include ‘second-generation’ techniques that are simpler and safer than conventional methods. In common with all surgical procedures, adequate information and counseling are essential in the decision-making process

Endometrial ablation

The object of endometrial is the complete destruction of the endometrial down to the basal layer, resulting in fibrosis of the uterine cavity and amenorrhea . In practice it is very difficult to achieve complete destruction, and rates of amenorrhea are rarely in excess of 20-30 per cent. However, patient satisfaction rates are over 70 per cent in the short term .

Established techniques carried out under direct hysteroscopy vision involve the use of fluid for distension and irrigation . These comprise:

Laser ablation,
Endometrial loop resection using electro diathermy,
Roller ball electro diathermy ablation.

Of these, laser ablation is limited by its costs to a very few centres. All three are operator dependent, time consuming and carry risks of systemic fluid absorption, haemorrhage and uterine perforation with heat damage to adjacent structures.

Newer techniques have been developed with the object of reducing operator dependency and minimizing risk. Of these, the best evaluated to date are microwave and thermal balloon ablation. Endometrial ablation should be offered as a treatment option to women with a history of failed medical treatment for menorrhagia .

KEY POINTS

Clinical presentation with heavy menstrual bleeding may be influenced by the presence of other menstrual complaints .
Young women presenting with Intermenstrual or postcoital bleeding should be tested for Chlamydia .
Primary investigation of abnormal bleeding should be by TVS and endometrial biopsy followed by hysteroscopy if findings are abnormal or equivocal .
NSAIDs and antifibrinolytics are effective in the management of menorrhagia .
The COCP is effective for menorrhagia provided there are no contraindications
Cyclical progestogen are effective for menorrhagia when given for 21 days out of 28 and for control of anovulatory dysfunctional bleeding .
Continuous high-dose progestogen (e. g. depot preparations ) may be useful if they induce amenorrhea .
The LNG-IUS device is highly effective in relieving menorrhagia, but adequate counseling is needed prior to insertion .
Drugs that induce amenorrhea are useful for the short-term management of severe menorrhagia or for endometrial thinning prior to endometrial ablation .
Endometrial polyps and small sub mucous fibroids should be removed by hysteroscopy surgery.
Endometrial ablation is cheap, safe and effective for the relief of menorrhagia in the short term and outcome is best if it is carried out in women over the age of 45 .
Newer techniques of ablation are as effective as older techniques and are simpler to perform [I].
Long-term satisfaction is high with hysterectomy but it is associated with significant morbidity and mortality and should be offered only if simpler alternatives have failed
Vaginal hysterectomy may be more cost effective than the abdominal route but outcome is more dependent on the skill of the operator.
The route selected for hysterectomy should be determined by the skill and experience of the individual surgeon.

SOURCE: RCOG

Medical Specialists

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Consultant Obstetrician and Gynaecologist

Dr. Madhu Shree Vijayakumar

Dr. Madhu Shree Vijayakumar, is an obstetrician and gynaecologist with about a decade experience in addressing women’s health problems from adolescence to post menopause.

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Consultant Psychiatrist

Dr. Vijayakumar D.R

Dr. Vijayakumar D.R is a senior psychiatrist with more than 22 years of experience in handling mental health issues in India, Australia and the United Kingdom.

03/01/2019

Dysmenorrhea

OBG

Dysmenorrhea

INTRODUCTION

Pain during menstruation is an almost universal experience among women and, when severe, it has a significant economic impact through loss of time from work or education. Pain related to or exacerbated during menstruation or sexual intercourse may be a consequence of underlying pelvic pathology, although not all women with pelvic pain have a gynecological causes of cyclical pelvic pain but some reference is made to the multifactorial nature of the problem.

DEFINITIONS

Dysmenorrhea is pain that occurs during menstruation. Primary dysmenorrhea is also known as primary spasmodic dysmenorrhea. This is a useful descriptive term for a condition of cramping lower pain that may radiate to the lower back and thighs, often associated with gastrointestinal and neurological symptoms. It typically lasts for between 8 and 72 hours, although young women almost universally experience milder symptoms.

Secondary dysmenorrhea is menstrual related pain, which is secondary to identifiable pelvic pathology. It is characteristically associated with deep painful intercourse and the pain may precede the onset of menstrual bleeding. It is regarded as distinct from the condition of chronic pelvic pain in which pain of at least 6 months’ duration is present continuously or intermittently, not associated exclusively with menstruation or sexual intercourse. However, there is considerable overlap between the two conditions.

PREVALENCE

The prevalence of chronic pelvic pain among women aged 18-50 years is around 15 per cent.

CAUSES

Uterine hyperactivity has been demonstrated in women with primary dysmenorrhea. The response represents the extremes of the normal physiological response of the uterus to progesterone withdrawal, as primary dysmenorrhea is not regarded as pathological condition.

Severe dysmenorrhea in young women is rarely due to any underlying abnormality. One exception is pain secondary to congenital abnormalities that are associated with obstruction to menstrual flow, for example cryptomenorrhoea in an accessory uterine horn.

Many of the conditions that cause secondary dysmenorrhea may also present with chronic pelvic pain, in particular endometriosis, which occurs in around one-third of laparoscopies carried out for pelvic pain . Adenomyosis is a cause of secondary dysmenorrhea in older multiparous women. Uterine fibroids do not characteristically cause pain unless there is an acute complication such as torsion or expulsion.

Around one-third of laparoscopies carried out for the investigation of pelvic pain or secondary dysmenorrhea are negative . This must not be interpreted as implying that the pain is psychogenic. Non-gynecological conditions can be exacerbated or enhanced during menstruation. In particular, irritable bowel syndrome is commonly diagnosed following negative investigations for pelvic pain. Pelvic pain may be musculoskeletal or nerve-related. Psychosocial factors are also important. Factors such as personality traits, coping strategies, health beliefs and influences of family members may predispose an individual to the development of chronic pain. There is also a high prevalence in women with a history of physical or sexual abuse.

Pelvic venous congestion is a condition described in multiparous women of reproductive age. Chronic dull, aching pain is characteristically exacerbated perimenstrually, by activity and by sexual intercourse, and relieved by lying down. It is attributed to the presence of dilated veins in the broad ligament and ovarian plexus.

MANAGEMENT

Investigation

Primary dysmenorrhea does not require investigation . If symptoms are atypical, giving rise to a suspicion of endometriosis or other pathology pelvic ultrasound is indicated. Although a simple pelvic examination can provide reassurance, this is not indicated in a teenager who is not sexually active . A transabdominal ultrasound scan will exclude uterine abnormalities or significant ovarian pathology and should provide reassurance if negative.

Abdominal and pelvic examination may be helpful in identifying tenderness and the presence of any masses. As endometriosis can only be diagnosed with certainty by laparoscopy , the nature and risks of the procedure require adequate discussion.

Management of primary dysmenorrhea

Non -steroidal anti- inflammatory drugs

These drugs inhibition of the enzyme cyclo-oxygenase. Ibuprofen, mefenamic acid and aspirin are all effective in primary dysmenorrhea. The overall incidence of side effects is low and generally related to the gastrointestinal tract

Combined oral contraceptive pill

These preparations have been widely used for many years for the relief of primary dysmenorrhea. The theoretical basis for their action is via inhibition of ovulation.

Alternative therapies

These are popular with the public and are widely used. These comprised vitamin B1 , vitamin B6 , vitamin E ( in combination with ibuprofen), magnesium , omega -3 fatty acids, and Japanese herbal combination.

New therapeutic approaches in primary dysmenorrhea

Non-steroidal anti-inflammatory drugs (NSAIDs) in current use inhibit two different is forms of the enzyme cyclooxygenase, known as COX- 1 and COX-2 . Selective inhibitors of the enzyme COX-2 may have similar analgesic efficacy but fewer of the side effects of the drugs in current use.

Secondary dysmenorrhea and chronic pelvic pain

Management of secondary dysmenorrhea will depend on its underlying cause. In cases of chronic pelvic pain where a diagnosis of endometriosis is suspected, laparoscopic confirmation of the diagnosis is unnecessary and a trial of medical therapy is justified provided that there are no other indications for surgery such as the presence of a suspicious adnexal mass .

Antidepressants

In the absence of pelvic pathology, there is a tendency for chronic pain to be attributed to depression. Although symptoms of depression and sleep disturbances may be more prevalent among women with chronic pain, the interaction is likely to be complex and not necessarily causative.

Progestogen for pain secondary to pelvic venous congestion

Although there is some dispute about the existence of the condition, treatment with continuous medroxyprogesterone acetate (MPA) has been advocated for women with chronic pelvic pain and dyspareunia attributed to the presence of pelvic varicosities.

KEY POINTS

Primary dysmenorrhea is experienced by more than two-thirds of women and a minority are severely incapacitated.
Investigation is unnecessary unless there are atypical symptoms or abnormal findings on pelvic examination .
Ultrasound is a useful non-invasive method for the detection of pelvic abnormalities.
NSAIDs are effective for the first-line management of primary dysmenorrhea.
COCPS are effective in primary dysmenorrhea .
Dietary supplements (magnesium, vitamin B1) may have a role in the management of dysmenorrhea.
Pain attributed to pelvic venous congestion is relieved by continuous high-dose MPA
Antidepressants are not effective in the management of chronic pelvic pain
Where possible, chronic pelvic pain should be managed in a multidisciplinary clinic.

Medical Specialists

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Consultant Obstetrician and Gynaecologist

Dr. Madhu Shree Vijayakumar

Dr. Madhu Shree Vijayakumar, is an obstetrician and gynaecologist with about a decade experience in addressing women’s health problems from adolescence to post menopause.

Facebook

Twitter

Consultant Psychiatrist

Dr. Vijayakumar D.R

Dr. Vijayakumar D.R is a senior psychiatrist with more than 22 years of experience in handling mental health issues in India, Australia and the United Kingdom.

03/01/2019

Medical Terms in OBG

OBG

Medical Terms in OBG

MEDICAL TERMS IN OBSTETRICS AND GYNAECOLOGY

Abortion	A way of ending a pregnancy using either medicines (medical abortion) or a surgical operation (surgical abortion).
Amniocentesis	A procedure to take a sample of the fluid surrounding a baby in the womb. It can be carried out after the 15th week of pregnancy, by inserting a needle through the abdomen into the womb. It can be used to detect the presence of conditions such as Down syndrome.
Amniotic fluid	The watery liquid surrounding and protecting the growing fetus in the uterus.
Anaemia	Anaemia is when the level of haemoglobin in your blood is lower than normal; it can be mild or severe. Anaemia can cause tiredness, breathlessness, fainting, headaches and your heart to beat faster.
Anaesthesia	A form of pain relief.
Antenatal	Before birth.

Bacteria	Organisms (so small that they are can only be seen through a microscope) that may cause certain kinds of infection.
Bacterial vaginosis (BV)	A very common vaginal infection which is caused by an imbalance in the types of bacteria in the vagina. It causes discharge and soreness. BV is not sexually transmitted. It does not affect men.
Bicornuate uterus (womb)	A uterus resembling a heart-shape (rather than the usual pear-shape).
Biopsy	A procedure to take a small sample of tissue from some part of the body for examination.
Bladder	The organ in the pelvis which expands to store urine and contracts to pass it out through the urethra.
Blood group	Your blood group is determined by the presence of chemical markers (known as antigens or proteins), on the surface of your red blood cells. Group A blood has A antigens, Group B blood has B antigens, Group AB blood has both A and B antigens and Group O blood has no antigens on the red blood cells.
Breech position	When the baby is lying bottom first in the womb.
Caesarean delivery	An operation to deliver the baby by cutting through the wall of the abdomen and the uterus. It may be done as a planned (elective) or an emergency procedure.

Cancer	The organs and tissues of the body are made up of tiny building blocks called cells. Cancer is a disease of these cells.
Cardiotocography (CTG)	A machine which traces the baby’s heart rate and the woman’s contractions before and during birth to assess the baby’s wellbeing.
Catheter	A small tube that can be passed through a part of the body; for example, through the urethra (to empty the bladder).
Cervix	The entrance or neck of the womb, at the top of the vagina.
Chocolate cysts	Cysts which form on the ovaries in some women who have endometriosis.
Chromosomes	The genetic structures within cells which contain our DNA (the material that carries genetic information). A normal cell contains 46 chromosomes.
Chronic	Something that persists or continues for at least six months.
Complete miscarriage	When all the pregnancy tissue has been passed and the uterus is empty.
Conception	A process which begins with fertilisation of an egg by sperm and ends with successful implantation of the embryo.
Contraception	Prevention of pregnancy.

Dilatation and curettage (D&C)	A small operation which opens the entrance of the womb (the cervix) in order to remove tissue from the lining of the womb (the endometrium).
Delivery	Birth of a baby and its afterbirth. A baby may be delivered through the vagina or by Caesarean section.
Doppler	A method for measuring the flow of blood; for example, through the umbilical cord during pregnancy.
Dysmenorrhoea	Painful periods.
Dyspareunia	Pain during or after sexual intercourse.

Ectopic pregnancy	A pregnancy where a fertilised egg (embryo) implants outside the womb (usually in one of the fallopian tubes).
Early miscarriage	When a woman loses her pregnancy in the first three months.
Eclampsia	A serious and life-threatening complication of pre-eclampsia. The main problem associated with eclampsia is fits (seizures/convulsions).
Endometrium	The lining of the womb (uterus).
Episiotomy	A cut made through the vaginal wall and perineum to make more space to deliver the baby.
Estrogen (previously oestrogen)	A female sex hormone produced by the ovaries as part of the menstrual cycle. It encourages an egg to mature and stimulates thickening of the lining of the womb in preparation for pregnancy. Levels vary during the menstrual cycle.

Fallopian tubes	The pair of hollow tubular organs that extend from the womb and end in fimbriae near the ovaries. Each month one ovary releases an egg which moves down the fallopian tube into the womb. The fallopian tube is where the egg is fertilised by sperm in the natural conception process.
Fertilisation	When a sperm penetrates an egg and forms an embryo. Natural fertilisation takes place in a woman’s fallopian tubes , but can be achieved outside the body by assisted conception techniques such as IVF.
Fertility	The ability to conceive a baby and, for a woman, to become pregnant.
Fertility problem	When you have not been able to conceive a baby. Fertility problems can affect men and women.
Fetus	An unborn baby.
Folic acid	A B vitamin necessary to reduce the risk of a baby being born with a neural tube defect (spina bifida). A woman should take folic acid (400 micrograms) 3 months before she conceives and for 12 weeks after she becomes pregnant.
Follicle	A small sac in the ovary, in which the egg develops.
Follicle stimulating hormone (FSH)	A gonadotrophin hormone produced by the pituitary gland. It stimulates the development of follicles in a woman’s menstrual cycle and regulates sperm and hormone function in men.
Forceps delivery	Smooth metal instruments that look like large spoons or tongs to help deliver the baby.

Haemorrhage	Bleed very heavily. A haemorrhage can happen: after 24 weeks of pregnancy (antepartum haemorrhage). during birth (intrapartum haemorrhage). immediately after birth (postpartum haemorrhage).
Heparin	A type of anti-coagulant medication that is given by injection.
Herpes	A family of viruses which cause a range of infections including chickenpox (Herpes zoster, or varicella), cold sores and genital herpes (Herpes simplex).
Hormone treatment	Hormones are produced naturally in the body. They control the activity of normal cells. Hormones can be given as treatment for disease or to replace hormones no longer produced by the body.
Hormones	Naturally occurring substances, made by specialised cells in the body, which affect the metabolism and other body functions. They can also be used as drug treatment. Naturally occurring hormones include: follicle stimulating hormone, gonadotrophins, human chorionic gonadotrophin, luteinising hormone, oestrogen, progesterone, prostaglandin. Synthetic hormones include some corticosteroids, progestogen.
Human immunodeficiency virus (HIV)	HIV is short for human immunodeficiency virus. It is a viral infection which attacks the body’s immune system, making it hard to fight off other infections. HIV is passed through contact with body fluids (blood, semen, breast milk).
Hypertension	Raised blood pressure.
Hypotension	Low blood pressure.
Hysterectomy	An operation to remove the cervix and womb, carried out through a cut on the abdomen (abdominal hysterectomy) or the vagina (vaginal hysterectomy) . The ovaries can be removed at the same time, if necessary.
Hysterosalpingo-contrast-sonography	An ultrasound test of the fallopian tubes or the womb, using fluid injected through the cervix (the entrance of the womb).
Hysterosalpin-gogram (HSG)	An x-ray of the fallopian tubes or the womb, using fluid injected through the cervix (the entrance of the womb).
Hysteroscopy	A procedure to examine the womb through a small telescopic microscope (called a hysteroscope) which is passed through the vagina and cervix.


Implantation	The process through which an embryo attaches to the lining of the womb.
In vitro fertilisation (IVF)	A technique by which eggs are collected from a woman and fertilised with a man’s sperm outside the body. Usually one or two resulting embryos are then transferred to the womb. If one or more of them implants successfully in the womb it results in a pregnancy.
Incomplete miscarriage	A miscarriage has started, but there is still some pregnancy tissue left inside the uterus.
Incontinence	When an individual does not have full control over the bladder and/or bowel. Problems with incontinence can range from slight to severe.
Induction of labour	When labour is started artificially.
Infertility	When a couple fail to conceive after having regular (defined as two to three times a week) sexual intercourse for more than a year.
Intensive Care Unit	A specialist unit within a hospital that provides intensive care medicine.
Intracytoplasmic sperm injection (ICSI)	A form of assisted conception in which a single sperm is injected into an egg.
Intrapartum	During birth.
Intrauterine contraceptive device (IUCD)	A small contraceptive device that is fitted into the womb. Made of plastic and copper, it has one or two soft threads at the end which hang through the cervix into the top of the vagina.
Intrauterine insemination (IUI)	A form of assisted conception which places sperm into a woman’s womb through the cervix.
Intrauterine system (IUS)	A small T-shaped contraceptive device that is fitted into the womb. Made of plastic, it slowly releases the hormone progestogen.


Karyotype	A record of the complete set of your chromosomes.
Karyotyping	A procedure to produce a karyotype using a blood or tissue sample. It is used to check for abnormalities in the number, form or structure of the chromosomes. These abnormalities may cause disease or dysfunction.


Labour	The stages of childbirth. Labour is divided into three stages; first, second and third.
Laparoscopy	A procedure in which a surgeon uses a small telescopic microscope (called a laparoscope) to look at or operate on part of the abdomen or pelvis.
Laparotomy	A surgical procedure through an opening (which is larger than that used for laparoscopy) into the abdomen.


Medical abortion	A way of ending a pregnancy by using medicines.
Menopause	The time when a woman’s periods cease, usually around 50 years of age.
Menstrual cycle	The process by which an egg develops each month and the lining of the womb is prepared for possible pregnancy. If the egg is not fertilised, it is reabsorbed back into the body and the lining of the womb (the endometrium) is shed (this is what is known as a period or menstruation) and the cycle begins again. The cycle is controlled by hormones. On average a cycle lasts 28 days. Some women have shorter cycles, some have longer ones.


Neonatalologist	A doctor who specialises in caring for newborn babies.


Obstetrician	A doctor who specialises in the care of pregnant women.
Oedema	Swelling in any part of the body predominantly due to ‘leaked’ fluids.
Oestrogen	A female sex hormone produced by the ovaries as part of the menstrual cycle. It encourages an egg to mature and stimulates thickening of the lining of the womb in preparation for pregnancy. Levels vary during the menstrual cycle.
Oligohydramnios	Too little fluid (amniotic fluid) surrounding the baby in the uterus.
Ovaries	A pair of organs (each about the size of an almond) in a woman’s pelvis. They produce follicles from which eggs develop.
Ovulation	The process by which the ovaries produce and release an egg each month. Ovulation usually takes place around 10-16 days before a period.


Pelvic inflammatory disease (PID)	An infection in the womb, fallopian tubes and/or pelvis caused by infections such as chlamydia and gonorrhoea . It can cause scarring or blockage of the fallopian tubes and fertility problems.
Pelvic pain	Pain in the lower abdomen or pelvis.
Period	A bleed from the vagina between every 3 to 5 weeks which forms part of the menstrual cycle.
Pessaries	A medication or device which is placed in the vagina.
Placenta	An organ which develops from the embryo in the womb during pregnancy. It links the baby with the mother’s system and provides it with nourishment. It is delivered after the baby, when it is also known as the afterbirth.
Placenta praevia	The placenta is too low in the womb and covers all or part of the entrance (the cervix). In most women, the placenta usually moves out of the way, as the womb stretches around the growing baby, and does not cause a problem.
Polycystic ovaries	Ovaries which have at least twice as many developing follicles as normal ovaries in the early part of the menstrual cycle.
Polycystic ovary syndrome (PCOS)	Polycystic ovary syndrome (PCOS) is a condition which can affect a woman’s menstrual cycle, fertility, hormones and aspects of her appearance. It can also affect long-term health. A diagnosis is usually made when a woman has any two of the following: irregular periods,more hair than is usual for you and/or blood tests which show higher testosterone levels than normal,an ultrasound scan which shows polycystic ovaries.
Polyhydramnios	Too much fluid (amniotic fluid) surrounding the baby in the uterus.
Postnatal	After birth.
Pre-eclampsia	A condition that occurs in pregnancy, usually associated with high blood pressure and protein in the urine.
Pregnancy test	A test on a sample of urine or blood to confirm whether a woman is pregnant.
Progesterone	A hormone produced as a result of ovulation. It prepares the lining of the womb to enable a fertilised egg to implant there.
Prolapse	A hernia where the bladder, womb or bowel pushes through the wall of the vagina.


Recurrent miscarriage	When a woman loses three or more pregnancies.
Reproductive organs	Organs in the male and female body designed to help reproduction.
Reproductive years	The time from the onset of menstrual periods (menarche) in women to the menopause, when periods stop.
Rupture of membranes	The medical term for the breaking of waters in pregnancy.


Semen	The fluid that contains sperm.
Sexually transmitted infection (STI)	An infection that is passed on through the close physical contact during sex. With some STIs you have no symptoms, so it is important to be tested if you think you have been at risk. See also chlamydia, genital herpes and HIV.
Spina bifida	A condition which affects the unborn baby in the early stages of pregnancy. Spina bifida causes damage to the spinal cord and nerves.
Spontaneous vaginal birth	The birth of a baby through the vaginal canal without assistance.
Sterilisation	A term for methods of permanent contraception for women ( tubal occlusion) and men ( vasectomy).
Stress incontinence	A condition which means you leak urine during normal everyday activities (for instance if you cough, sneeze, laugh, exercise or change position). Usually happens because the muscles that support the bladder are too weak.
Sutures	Stitches.


Tampon	A tube of absorbent material, such as cotton, that fits into the vagina to absorb the menstrual blood.
Temperature	The degree of hotness or coldness of a body or an environment.
Term	Between 37 and 42 weeks of pregnancy.
Threatened miscarriage	Bleeding or cramping in a continuing pregnancy.
Transabdominal scan	A scan. The scan probe is moved across the abdomen.
Transvaginal scan	An ultrasound scan where the probe is placed inside the vagina.
Transverse position	When the baby is lying across the womb.
Trimester	A three-month period of time. Pregnancy is divided into three trimesters: First trimester – up to around 13 weeks Second trimester – to around 13 to 26 weeks Third trimester – around 27 to 40 weeks.
Tubal occlusion	A permanent method of contraception for women through an operation which blocks, seals or cuts the fallopian tubes. Also known as sterilisation.


Ultrasound	High frequency sound waves used to provide images of the body, tissues and internal organs.
Umbilical cord (umbilicus)	The cord that connects a mother’s blood system with a baby’s (through its navel) and is cut after the birth.
Urethra	The tube through which urine empties out of the bladder.
Uterus (also known as womb)	The organ where a baby develops during pregnancy. Made of muscle, it is hollow, stretchy and about the size and shape of an upside-down pear.


Vagina	The canal leading from the vulva to the cervix.
Vaginal bleeding during pregnancy	Vaginal bleeding in pregnancy is bleeding coming through the vagina during pregnancy, for any reason.
Vaginal discharge	Any vaginal secretion apart from menstrual bleeding.
Normal vaginal discharge	A clear or whitish fluid that comes from the vagina or cervix.
Abnormal vaginal discharge	Abnormal smelling, yellow or green discharge. This should be assessed by a doctor.
Vaginal examination – Internal	A check to feel the size, position of the vagina and cervix to exclude any abnormality or problem. This may be carried out by use a speculum.
Vaginal swab	A vaginal swab looks like a cotton bud, but it is smaller and rounder. Some have a small plastic loop at the end instead of a cotton tip. It is wiped over the vagina to pick of samples of fluid to check for infection.
Vasectomy	A permanent method of contraception for men. It blocks, seals or cuts the tube (the vas deferens) which carries sperm from the testicles to the penis. Also known as sterilisation.
Ventouse delivery	An instrument (ventouse) that uses suction to attach a soft or hard plastic or metal cup on the baby’s head to help deliver the baby.


Weak Cervix	When the cervix (the neck of the womb) opens too early in pregnancy, in the second trimester, and without contractions. Used to be known as ‘incompetent cervix’.
Womb	Uterus.

Medical Specialists

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Dr. Madhu Shree Vijayakumar

Dr. Madhu Shree Vijayakumar, is an obstetrician and gynaecologist with about a decade experience in addressing women’s health problems from adolescence to post menopause.

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Consultant Psychiatrist

Dr. Vijayakumar D.R

Dr. Vijayakumar D.R is a senior psychiatrist with more than 22 years of experience in handling mental health issues in India, Australia and the United Kingdom.

03/01/2019

Did you know?

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Did you know?

Did you know?

You have two ovaries, one on each side of your uterus. Ovaries are the size and shape of almond and contain your ova or eggs.

The fallopian tubes are near the ovaries. These are thin , about 10cm long and they carry egg from ovary to womb(uterus).

The uterus is pear shaped hollow structure .It can stretch to hold a baby and shrink back after delivery.

Cervix is the lower part of uterus which connects to vagina. when a woman is pregnant ,the cervix is plugged with mucus to protect the developing baby from infection.

Your vagina is about 8-10 cm long which leads your cervix to the entrance(vulva).

The menstrual cycle

The menstrual cycle is the process in which an egg develops, released when signals are given by the gland, if conception does not happen prepares the uterus to bleed, but if conception happens prepares the lining of uterus for a possible pregnancy. These events are caused by chemical messengers or hormones.

Ovulation is when egg is released from ovary. Once released ,it travels down the fallopian tube to uterus..After ovulation the mucus in the cervix becomes thick and sticky. If the egg is not fertilized it will be reabsorbed naturally , hormone levels falls and menstrual cycle ends. The cycle begins with shedding of womb lining as periods.

Conception

It is a process that begins with fertilization. For fertilization to take place an egg needs to meet a sperm following intercourse. It takes about 3 hours for the sperm to fully enter the egg. . The fertilised egg moves down the fallopian tube to the prepared womb for implantation . conception is now complete and pregnancy begins.

An average pregnancy lasts 280 days

Very rarely a pregnancy develops outside the womb, usually in the fallopian tube , this is called ectopic/ tubal pregnancy.

Medical Specialists

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Twitter

Consultant Obstetrician and Gynaecologist

Dr. Madhu Shree Vijayakumar

Dr. Madhu Shree Vijayakumar, is an obstetrician and gynaecologist with about a decade experience in addressing women’s health problems from adolescence to post menopause.

Facebook

Twitter

Consultant Psychiatrist

Dr. Vijayakumar D.R

Dr. Vijayakumar D.R is a senior psychiatrist with more than 22 years of experience in handling mental health issues in India, Australia and the United Kingdom.

03/01/2019

Managing Infertility

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Managing Infertility

A guide to managing infertility.

The desire to have a child is natural, and most women plan on experiencing pregnancy and childbirth at a certain point in their adult lives. Although conceiving a child may seem like the easiest thing in the world, it is actually not the case for many couples.

This explores the implications of infertility and treatment options- the effects it can have on you, your emotions, your sexuality and your relationships. It also outlines a number of ways in which you and your partner can cope with the problem of infertility.

Background on infertility.

Infertility is generally defined as the inability to conceive after one year of trying to become pregnant. Most couples assume that they are fertile and expect to conceive soon after they stop using birth control. However, 10% of all women of childbearing age are infertile, and about one quarter will experience at least one period of infertility sometime during their lives.

Causes of infertility.

Most couples that have difficulties achieving pregnancy are not sterile, but are usually infertile or subfertile (having a reduced chance of conceiving spontaneously in the normal way).

The most common known causes of infertility are spermatozoal defects, ovulatory disorders and tubal disease. But the biggest group is due to “unexplained infertility”. This is when a couple fails to conceive after 18 months of regular intercourse, and no cause is found.

Among couples who seek medical help, infertility is exclusively a problem in the female in about 40% of cases, and exclusively in the male in about 30% of cases. In the balance of cases, infertility results from problems in either partners or the cause of the infertility cannot be explained.

• The World Health Organisation believes that between 60 to 80 million couples in the world are infertile.

• Between 2 – 10% of couples are unable to conceive a child by natural means, and a further 10 – 25% are unable to have a second or subsequent child.

• It is estimated that about 1 in 6 couples seek help in trying to achieve a pregnancy. This help can range from basis advice from their doctor, to undergoing in vitro fertilization (IVF) therapy.

Treatments offers hope.

A diagnosis of infertility does not have to mean childlessness. It can often just mean that becoming pregnant is a challenge- one that can be aided significantly by medical treatment. Today’s treatments offer a good rate of success, and approximately three out of four women will get pregnant as a result of treatment.

Experiencing infertility.

To have your family is a universal dream, and the thought of not being able to can make you and your partner feel that something is wrong with you.

Learning that you have an infertility problem can lead to painful and difficult emotions. It involves rethinking many things you may have taken for granted: children and family life, genetic continuity, the experience of conception, pregnancy and birth, the meaning of your life plan and marriage, and your sexuality.

The following are examples of common feelings experienced by many couples dealing with infertility.

Confusion.

“I simply assumed I was fertile. I took birth control for years to avoid pregnancy, and it seems very ironic that I can’t conceive now. I don’t know why I can’t. I feel very confused about the whole situation, and it’s hard to make sense of it all.”

Frustration.

“I learned about my infertility only after trying to become pregnant for some time. Now my life seems on hold, and a lot of my time spent on medical appointments, tests, and treatments. Sometimes I feel frustrated and powerless.”

Fear.

“For me, going through infertility brought up a lot of fears and questions. How long would it last? What if I never became a pregnant? Why didn’t my body do the things I wanted it to do? I was afraid of my feelings, afraid of my body and afraid of the future.”

Isolation.

“I feel like I was the only woman I knew who was going through it. I stayed away from my friends because seeing their own children hurt me terribly. I felt very alone, like no one understood me.”

Guilt and shame.

“I couldn’t accept that it was a medical problem. I began to blame myself, and wondered why I was being punished. I couldn’t figure out what I’d done to deserve infertility. My self- esteem was at the rock bottom and I felt like a failure. I began to worry about what my family would think, and if my husband would stay with me if we couldn’t get pregnant.”

Anger.

“Everything makes me angry these days. My body, my partner, my family and friends. I get very upset when I hear about child neglect or abuse, because why should those people have children if they aren’t capable of loving them? I also get angry when I have to listen to well- intentioned advice. Hearing comments like ‘you’re not trying hard enough’ or ‘you should consider adoption’ just send me into a rage.”

Sadness and hopelessness.

“I feel like my future is hanging in the balance, and that I can’t hope for anything. I’m sad about the strain that infertility puts on my marriage and career. I’m very sad that I’ve had to put my life on hold while I try to get pregnant. I hate not having any definite answers or guarantees.”

Dealing with infertility as a couple.

Infertility can bring many changes to your relationship as a couple. It may bond your closer together, as mutual support and understanding leads to greater sharing and intimacy. But it can also bring forth feelings of guilt and resentment, particularly if no resolution is in sight. As a couple, you may have a lot of feelings in common when dealing with infertility, such as feeling out of control of your lives and your emotions.

Loss of control.

You and your partner have probably planned your lives to begin a family at the most favorable time. You may have practiced birth control for years and waited until your careers were established before trying to conceive. A diagnosis of infertility can remove the feelings of control over your life together.

Expressing feelings- the differences.

You and your partner are also affected by infertility in different ways, related to how men and women have been socialized to think, feel and act.

As a woman, you may feel responsible for much of the burden of infertility in a way that your husband may not. As a result, you can experience negative feelings, such as pain, anger, and fear, which can lead to anxiety and depression. These feelings are very common, and often the resulting friction can cause problems in your relationship.

As a man, you may often feel more threatened expressing yourself since you’ve often been taught to repress your emotions. You are trained to take charge, to make decisions, and to think without being emotional. You tend to focus your energy on your work, a place where you feel you can have more control. You may also feel overwhelmed by the intensity of your partner’s emotions, which makes it hard for you to offer support.

You may both feel that no one else understands what you are going through, and may isolate yourselves from potential sources of support such as friends and other family members.

A stronger relationship.

Infertility can test your relationship in a variety of ways, but providing mutual emotional support and working together can reduce some of the stress and help to avoid creating distance. It may even strengthen your relationship, as you both learn to give reassurance and encouragement, and realize that you can really depend on each other.

Sexuality.

Failure to conceive affects both self- esteem and self- worth. This negative is sometimes reflected in a couple’s sexuality, which can be compounded by it being seen as the “source” of the infertility problem. After all, most people see fertility as a logical consequence of a couple’s sexuality.

As time passes, you may find that sex loses its pleasurable aspects and feels like something of a chore. You and your partner may become aware of a loss of spontaneity, as medical procedure, temperature charts, and sex on a schedule can combine to take the joy out of your sex life. You may lose sight of each other and what brought you together as a couple.

These important feelings can effect your sex life, but it is important to remember that you can help each other through the difficult times. Share your feelings with each other. Remember that your life together as a couple is rich and varied, and is not defined solely by your ability to conceive.

Infertility and your relationship.

Infertility can have a significant impact on your relationship. It affects both partners physically, psychologically, socially and economically. Couples often report a wide range of emotions, including:

• Anger at infertility for taking over their lives.

• Anger at the inequity of infertility treatments. In most cases, women carry more of the burden than men do.

• Frustration over treatments that don’t guarantee a baby, after spending a great deal of time and emotional energy.

• Financial worries.

• A heightened sense of sensitivity and vulnerability.

• Frustration at the inability to make short- and long- term plans.

• Self- punishment – “perhaps I don’t deserve to have a child”

• Blame- “if only we’d done this or that, then we’d have a baby”.

• Desire to fight back and gain control of the process.

How your partner can help.

Your partner cares about you and how infertility is affecting your relationship. Your partner wants to help you in any way possible, and this section is intended to help both of you.

What you as a partner can do:

Infertility is a couple’s problem and is best approached as a team, through the commitment of both partners. Here are some ways in which you can support your partner during this difficult time.

Be a listener.

Ask them if they need to talk. Let them know that you are available for them. While listening, try to maintain an open mind and be supportive. Remind them that you love them no matter what. If they need additional support such as counseling, accompany them to appointments and attend counseling yourself if need be.

Be sensitive.

Don’t try to pretend that everything will be ok. Don’t trivialize their feelings, or give them empty reassurance.

Remember that working through infertility is a process that takes time. There are no guarantees, no package deals, no one right answer, and no quick choices. Your partner also needs patience as their feelings change. Don’t minimize or evaluate their feelings. Just allow these and give them time.

Stay informed.

This will help you maintain perspective about the array of choices you must make as a couple. The more information you have, the more knowledgeable decisions you can both make about your options.

Do things as a couple.

Enjoyable experiences such as a lunch date, a shopping trip or a visit to a museum, help you both feel there is a outside of infertility.

Remember that your willingness to listen and support can go a long way towards helping you both handle the stress you are experiencing. Infertility is probably one of the most difficult situations you will ever have to deal with.

Managing infertility:

What you need to know about infertility treatment.

Starting out.

If you suspect your problem with your infertility, the best thing you can do is to take immediate actions. The earlier a problem is identified, the sooner your physician can recommend the treatment program that is right for you. Responding to early concerns about infertility can increase your chances for a successful outcome.

When should I seek treatment for infertility?

Infertility starts as soon as you seek professional help. Many infertile couples undergo a long process to attempt to conceive with no guarantees of success. On the other hand, there are couples who become pregnant soon after their first appointment with the fertility specialist, without any treatment at all.

Should my partner accompany me to the specialist?

It takes two people to make a baby. Since both you and your partner are involved in the process, it is only fair that you both are part of it. The infertility specialist will be able to discuss with both of you and to also outline the chances of success and the possibility of failure.

What is the success rate of infertile couples getting pregnant with treatment?

Over half of the couples with more than two years of infertility eventually become successful in achieving pregnancy. With advances in infertility research and wider availability of newer techniques, the success rate of infertility treatment is increasing all the time.

Infertility treatments and procedures.

Over the past decade or so, improvements in techniques and procedures in reproductive medicine have increased the variety and availability of procedure to assist couples in achieving pregnancy. The treatment recommended for you will depend on your particular diagnosis and your decision on which direction your treatment will take.

Treatment may include timing of intercourse, hormone therapy, intrauterine insemination (IUI) to bypass problems with sperm/cervical mucous interactions, in vitro fertilization (IVF) with embryo transfer, gamete intra fallopian transfer (GIFT), or intracytoplasmic sperm injections (ICSI).

During the course of your evaluation, various testing procedures to determine male partner status, uterine/ovarian status, and tubal status will provide your doctor with information to recommend treatment options for you. Often your doctor will decide on a less invasive treatment plan at the first, such as timed intercourse or IUI. However, if the treatment does not result in pregnancy after several cycles, your doctor will likely recommend another treatment, such as IVF or ICSI.

Whatever the treatment plan, the ultimate decision remains with you, your partner and your doctor. Read on for more information about treatments and procedures to begin your education process.

Timed intercourse.

This is the most basic treatment for infertility. If testing determines that your tubes are clear, follicular development, endometrial development and semen analysis are normal, you can attempt pregnancy through timed intercourse. This procedure may include using a urine surge test kit to determine the time of ovulation upon which you and your partner will have intercourse at a given time. This is done to ensure that the sperm is in the fallopian tube at the time the egg is released and begins to travel down the tube.

A more advanced form of this treatment may include a monitoring ultrasound to determine follicular development and the development of the uterine lining. An injection of Human Chorionic Ganadotropin (HCG) can be given to induce ovulation and set up the timing for intercourse.

IntraUterine insemination (IUI).

This procedure also known as “artificial insemination”, involves placing washed sperm into the uterus with a small catheter through the cervix. Sperm can be form the partner or form frozen donor sperm, depending upon your needs. IUI is often performed if you have had failed attempts at timed intercourse or if there is a determination of abnormal cervical mucous/sperm interaction, poor mucous, or hostile mucous which renders the sperm unviable. In the latter case, sperm are injected past the cervical barrier to enable them to move into the fallopian tube and reach the egg.

Variations in the procedure include taking medications to produce multiple follicles and the release of more than one egg in order to achieve fertilization.

Advantages of IUI.

• Minimally invasive.

• Less emotional commitment.

• Less time- consuming.

Disadvantages of IUI.

• Fertilization cannot be confirmed.

• Risk of multiple pregnancies.

• Tubes must be unobstructed.

In vitro fertilization- embryo transfer (IVF).

IVF is probably the most common used of the Assisted Reproductive Technologies (ART). It is often known as the “test tube baby” procedure and has helped infertile couples conceive and bear children for well over two decades.

In order for a pregnancy to occur, an egg must be released from the ovary and unite with a sperm. This union, called fertilization, normally occurs within the fallopian tube. During the process of IVF, however, this union takes place in a laboratory after both eggs and sperm have been collected. The fertilised eggs are then transferred to the uterus to continue growth.

Down- regulation.

Medication is given which temporarily switches off the messages going from the brain to the ovaries telling them to produce an egg on a monthly basis. In additional, down regulations prevents premature release of the egg. Thus, down regulation primarily serves to ensure correct timing of ovulation prior to egg collection.

To ensure that the medication has worked, a blood sample is taken to check the level of oestradiol (one of the oestrogen hormones) and sometimes by performing an ultrasound scan of the ovaries and the womb (uterus).

Ovarian stimulation and follicular monitoring.

Gonadotropins (e.g. HMG – human menopausal Ganadotropin) are given to stimulate the ovaries into producing the follicles, which contain the eggs. HMG contains equal parts of FSH (follicle stimulating hormones) and LH (luteinizing hormone). Both hormones are natural parts of the follicle stimulating process. Treatment with HMG lasts 1 to 2 weeks and involves a once- daily subcutaneous injection.

Your doctor or nurse will teach you have to give the injections yourself. The length of treatment will depend on how your ovaries respond; ovary response will be monitored with the use of ultrasound and a blood test that measures your oestrogen levels. Once ultrasound shows that the lead follicle has matured in size, HCG will be injected to trigger the release of the egg.

Egg retrieval and embryo observation.

Thirty- six hours after the injection, retrieval of the eggs is undertaken. The procedure itself is formed at the hospital/ clinic most often by a transvaginal route. A needle, guided by ultrasound imaging, is inserted through the vaginal wall into the ovaries, where the follicles containing the eggs are punctured and the eggs withdrawn. The released eggs are transferred to the lab where their development stage is assessed. This procedure is usually done under a mild sedative or general anaesthetic. The procedure takes about 10-15 minutes, and you can return home a few hours after it. A sperm specimen is then washed and prepared for insemination. Each dish is placed in an incubator. The embryos are then observed for a few days for normal fertilization under a microscope.

Embryo transfer.

If fertilization is successful, the embryo can then be transferred to the uterus. The transfer techniques is accomplished by placing a maximum of 3 embryos inside a narrow plastic tube (transfer catheter) which is then inserted into the uterus through the cervix. The process lasts only a few minutes. You may then rest for a couple of hours, and return home where you often are advised to take it easy for 1 or 2 days.

Luteal phase support.

In some cases, supplemental Progestogen is occasionally used to improve the secretion of progesterone and estrogen during the luteal phase. It is administered in different to improve chances of implantation.

Pregnancy test and ultrasound.

A blood or urine pregnancy test will be taken. If the test is positive, an ultrasound examination will be arranged within the next two to four weeks. Once ultrasound confirms the presence of a healthy pregnancy, your doctor will discuss plans for pregnancy care with you.

Cases in which IVF may be recommended.

• Tubal disease.

• Endometriosis

• Cervical problems

• “Unexplained” infertility.

• Failure of IUI.

Advantages of IVF.

• Fertilization is confirmed.

Disadvantages of IVF.

• Technical demanding.

• Risk of multiple pregnancies.

• Price/costs.

The IVF- process at a glance.

There are several major steps to the in vitro fertilization (IVF) process.

All of these are done on an outpatient basis:

• Down regulation of the pituitary, depending on which IVF protocol is used.

• Stimulation and monitoring of the follicles.

• Collection of the eggs.

• Collection and preparation of the sperm sample.

• Incubation of the eggs and sperm together in the laboratory, to allow for fertilization and early embryo development.

• Transfer of the embryos into the uterus.

• A two- week wait for a pregnancy test.

Intracytoplasmic sperm injection (ICSI).

ICSI is a type of assisted microsurgical fertilization that involves the injection of a single sperm directly into an egg. Over the last few years, various methods of assisted microsurgical fertilization (micromanipulation procedures) have been developed for use when the male partner exhibits poor sperm motility and/or low sperm count. ICSI allows a much higher fertilization rate for these patients with “normal” fertilization in over 50% of eggs. Eggs for ICSI are obtained in exactly the same way as those for IVF.

Following egg retrieval, the cells surrounding each egg are carefully removed. The eggs are then examined under a microscope and only those that are judged as mature are suitable for injection. Typically, 70% of the eggs that are obtained are suitable for ICSI. The sperm are washed and prepared. The egg and the sperm are then placed on a special microscope that has micromanipulator holds the egg in place, while the other is used to inject the sperm into the egg. The remainder of the procedure is similar to standard IVF with regard to incubation of the eggs and transfer of the resulting embryos.

Cases in which ICSI may be recommended.

• Very low number of motile sperm with normal appearance.

• Problems with sperm binding to and penetrating the egg.

• Antisperm antibodies (immune or destroy sperm) of sufficient quantity to prevent fertilization.

• Prior fertilization failure with standard IVF culture and fertilization methods.

• Absence of sperm in the seminal fluid.

Advantages of ICSI.

• Most effective procedure for male infertility.

• Overcomes some sperm quality problems.

Disadvantages of ICSI.

• Possibility of transmitting infertility to offspring.

• Technically demanding.

• Price/costs.

Awaiting the outcome.

Fertility treatment can bring with it a certain degree of emotional strain. The process is emotionally and physically demanding, often seems outside your control, and has no guarantee of a successful outcome- all of which can increase your stress levels. While most couples cope well with the stresses of IVF procedure, all couples will feel the pressures to some extent.

Taking control.

There is no escaping the stress of infertility treatment, but there are ways in which you can manage or reduce the stress and regain a sense of control over your life. Try these strategies to help you cope with the demands of fertility treatment:

• Approach the infertility problem together with your partner as you would with any project. Your doctor can help both of you map out a strategy and a timetable.

• Collect information on the internet. There are many useful websites dealing with the subject of infertility.

• Try to keep the lines of communication open with your partner. This may not always be easy, but you need to support each other and communication is vital.

• Don’t be afraid to talk to others who have undergone fertility treatment. Their experiences will help you know you are not alone. Keep in mind, however, that everyone is unique and your situation is not exactly like anyone else’s.

• Don’t dwell on the short- term ups and downs of treatment. It is perfectly normal to feel frustrated and angry when things aren’t going you planned.

• Allow yourself to feel down when you have reached your limit. Remember that you are okay although you’re having trouble conceiving a baby.

• Consider taking time off from treatment if it becomes overwhelming.

• Make a date to have sex for fun during the “nonfertile” times of cycle. Try to bring back your original closeness.

• Try to redirect your focus toward something positive, such as a favourite hobby or new activity.

• Seek emotional support from a councilor or support group.

The result- before and after.

In particular, you can expect you and your partner’s stress levels to rise during the periods of waiting, for confirmation that fertilization has occurred and for a positive pregnancy test:

“You are sort of on a knife edge. You go into hospital and have the eggs taken out and then the sperm’s mixed and you feel you have to wait forever. You are so nervous and just hope for the best.”

“The hardest part of all has been the ups and downs. You go from the very heights to the bottom with just one phone call.”

For many couples, a negative result can mean intense disappointment: “When I had a negative test no one could have prepared me for how devastated I was going to feel. I just screamed and cried and was desperately upset, and I wasn’t prepared that I was going to be that upset.”

“It was worse with IVF, knowing that you’d had 3 embryos put back. It doesn’t hit you straight away. No one who hasn’t been through this can understand what if feels like. We’ve both lost people close to us, but this is a different type of grieving, you’ve got nothing to remember what you are grieving for and it’s devastating.

These experiences are in stark contrast to the elation felt by women who achieve pregnancy:

“I don’t think that until a few months ago it dawned on me that I’d actually got the healthy children that I wanted.”

“I can’t believe it still- after this length of time. I can’t believe that I’ve got a baby, and neither my husband.”

Stay positive.

Although going through treatment can be very hard on you, it is important to remember that there is always hope, and success may be achieved after considerable effort. Even in normal fertile couples, there is no guarantee of conceiving right away, it may take time and repeated efforts. Remember that a successful resolution may be just around the corner for you, too. This can make it all worthwhile.

Finding ways to cope.

Infertility is an experience that continually fluctuates in intensity, so that at different times you may have different needs and experience different emotions. You must find your own ways of coping with the situation, and the following section provides a range of ideas on how you can take care of yourself and your partner during this difficult time.

Realize that infertility is a life crisis.

Infertility may be one of the hardest situations you’ll ever face. It can call into question the most fundamental expectations you have for yourself, your body, and your relationship. It’s normal to feel a sense of loss, to feel stressed, depressed, or overwhelmed.

Educate yourself.

Read as much as you can and don’t be afraid to ask questions. This is particularly important when dealing with infertility because the technology is complex and changes so quickly. Talking with your doctor and understanding your options enables you to make informed choices.

Don’t blame yourself.

Negative thoughts only make things seem worse. When you start feeling like you “should have” or “could have,” try to remind yourself that infertility is not your fault. Concentrate on the present and the future, and how you and your partner are going to manage the current situation.

Maintain your emotional partnership.

Couples often feel like adversaries during this time. Do your best not to place blame, and instead try to help each other. This doesn’t mean you need to feel exactly the same way at the same time (most experts say couples are often out of sync), but it does mean sympathizing with your partner’s situation. If you’re taking care of each other emotionally, you can unite to fight the problem.

Decline invitations to baby- focused activities.

If certain gatherings or celebrations (such as christenings) are too painful, give yourself permission to avoid them. Your friends and family will understand.

Get support.

Society often fails to recognize the grief caused by infertility, which leads those struggling with infertility to hide their feelings. This only increases feelings of shame and isolation. Finding others who are going through the same thing can help you see that you are not alone and that your feelings are reasonable. Openly discussing your emotions can relieve tension, and can sometimes contribute to a higher pregnancy rate.

Consider counseling.

If you and your partner feel strained and isolated from one another, you may want to consider counseling. This has proven a very successful resource for many couples, and you may find it helps you share a new level of mutual respect and understanding. The ability to get through this together can open new doors to the future and deepen your relationship in a variety of ways.

Keep your perspective.

When it comes to fertility treatment, there are no guarantees. Trying to stay realistic can help you make smarter choices as you work your way through the emotional minefield of fertility treatment.

Pursue other interests.

Although you may feel like being treated for infertility ia a full- time job, it’s important to participate in some of the activities or hobbies that bring you pleasure. If you find that your old activities are painful- may be all your friends are parents now- look for a new diversion.

Setting limits, taking breaks.

Only you and your partner can decide your limits. Here are some questions you might want to ask yourself if you feel that treatment is too stressful, or if you may need to take a break from treatment:

• Do you feel that you are just going through the motions of treatment?

• Do you feel that you would have no regrets if you stopped treatment today?

• Have you and your partner drifted apart because of the infertility problem?

• Have you lost touch with yourself and your goals?

• Are you comfortable with other options available to you?

Often, taking a pause from fertility treatment can provide a release of tension and some needed perspective. Some couples even find that they achieve pregnancy at this point. Discuss it with your doctor, and consider whether taking a break is right is right for you.

Easing stress.

Here are some coping strategies that can help through this trying time.

• Read and learn as much as you can about infertility.

• Communicate fears and emotions to your partner on a regular basis.

• Support one another, but understand that at times it will be difficult to do this.

• Acknowledge the fact that periods of depression and anxiety may happen.

• Try to eliminate stressful activities.

• Allow yourself private time.

• Share your problems with supportive friends or other family members.

• Go to doctor appointments together so you both understand the tests and procedures.

• Write all of your questions down prior to your appointments so you don’t forget to ask your doctor to address each of your concerns.

• Take care of yourself by pursuing other interests.

• Discuss limits with your partner.

Medical Specialists

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Consultant Obstetrician and Gynaecologist

Dr. Madhu Shree Vijayakumar

Dr. Madhu Shree Vijayakumar, is an obstetrician and gynaecologist with about a decade experience in addressing women’s health problems from adolescence to post menopause.

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Consultant Psychiatrist

Dr. Vijayakumar D.R

Dr. Vijayakumar D.R is a senior psychiatrist with more than 22 years of experience in handling mental health issues in India, Australia and the United Kingdom.

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03/01/2019

The Menopause

OBG

The Menopause

INTRODUCTION

‘What is Menopause?’

The Menopause is a time of change in your body, and often in your life too.

You may find this time to enjoy and take control of your life, when you have more time and energy for yourself.

Or you may find that the changes taking place in your life make you feel anxious or low.

When will it happen to me?

It usually happens between the ages of 45 and 52, although it can happen earlier or later.

What causes it?

The monthly cycle is controlled by two natural chemicals called hormones, oestrogen and progesterone. These prepare the body for pregnancy each month. When pregnancy doesn’t occur, you have a period.

As you grow older, your ovaries are less able to produce eggs each month and the level of oestrogen falls. Your periods will probably become irregular and unpredictable, until they finally stop altogether.

What are the symptoms?

Hot flushes, night sweats and felling emotional are all common symptoms of the menopause. They are caused by hormonal changes and vary from women to women. They may start before your periods stop, or develop several years later. They may be mild or they may be unpleasant and distressing. Irregular periods are another common sign that the menopause is approaching.

Irregular periods.

Your periods may become erratic and unpredictable some months or years before they actually stop. The flow might start to vary, from heavy one month to light the next. If your periods are very irregular or very heavy, see your doctor.

Hot flushes and night sweats.

These can occur any time before or during the menopause. They can be uncomfortable, but they are not harmful. Some women have none at all.

Hot flushes and sweats usually happen in the week of your period in the lead up to the menopause. After your periods have stopped, they may happen more frequently.

Hot flushes can happen on and off throughout the day, and may affect your sleep at night. They are probably caused by hormonal changes, but the exact cause is not known. You feel a wave of heat passing over your body, sometimes accompanied by redness, sweating or tingling. This can last for a number of seconds or up to several minutes. You may also feel a little faint and dizzy, and you may fell your heart beating faster.

Sweats can happen with or without a flush, usually at night. After sweating, you can feel very cold. Night sweats can make it very hard to get a good night’s rest.

Dryness in the vagina.

Your vagina may become drier, which can make sex painful or uncomfortable and increases the risk of vaginal inflection. There may also be an increased risk of cystitis (bladder infection). If you notice any unusual discharge from your vagina, this may be sign of infection ,see your doctor.

Feeling emotional.

At this stage in their lives, many women experience symptoms such as headaches, forgetfulness, irritability and feeling low. For some, it is the worst aspect of menopause. As well as struggling with your own feelings, you may also worry about the effect of your mood swings on the people around you.

The changes in your body may certainly be responsible for some of these feelings. Mood changes may become worse around the time of your periods, for example due to increased premenstrual tension. But there may be other reasons for feeling emotional or down, particularly due to the changes and stresses in your life.

If you do not feel depressed, find someone sympathetic to talk to. This could help you understand why you are feeling the way you are. You could try talking to friends or relations who have gone through menopause and your doctor.

When can I stop using contraception?

It’s best to discuss this with your doctor . Generally, women under 50 are advised to wait until they have had no periods for two years before stopping their method of contraception. Women over 50 should wait one year.

Remember the ‘natural’ methods of birth control such as safe times or temperature monitoring is not reliable once your periods become irregular. Also, some forms of the pill might not be advisable around the time of the menopause, especially if you smoke. Again, discuss appropriate methods with your doctor.

What can I do to help myself?

Some women have little or no trouble with the menopause. Don’t assume it’s going to be awful- every woman has a different experience. Even if you do have problems, there’s a lot you can do to help yourself.

• Be prepared. If you experience sweating at night, try lying on a large towel and use cotton night clothes and sheets. Keep a fan and bottle of cold water by your bed. If you get hot flushes throughout the day, wear layers of clothing that you can take off. Deep breathing can help to ‘cool down’ hot flushes.

• Eat a healthy, balanced diet. Eating sensibly and well is important for good health and for the prevention of osteoporosis.

• Avoid smoking. If you smoke, try to quit. Smoking may make menopause start about one year earlier. It also increases the risk of osteoporosis and heart diseases.

• Stay active. Regular physical activity can also help you feel better. Try to treat this as a time to relax and reduce stress in your life.

• Use a vaginal lubricant. If dryness in your vagina makes sex painful or difficult, try using a lubricant such as KY jelly, available from any chemist.

• Consider Hormone Replacement Therapy. It can bring significant relief to menopause symptoms, including hot flushes, night sweats .

Should I talk to my family about what’s happening to me?

Talking things through with your family, friends and colleagues can be very positive. Partners and families may be worried about the effect the menopause will have.

If you are in a relationship, it’s important to help your partner understand what is happening and how you feel. If your symptoms seem to be causing difficulties, discuss how you can improve things.

Since men don’t have a physical menopause themselves it’s hard for them to understand what a woman goes through at this time. Men often have emotional problems of their own in middle age, feeling nervous, irritable, tired or experiencing loss of confidence. It’s importance to keep communicating and supporting each through what can be a time of change for both of you.

Osteoporosis.

Osteoporosis, or thinning of the bones, affects both men and women. But it can be a problem for women because of the hormonal changes that occur at the menopause.

When bones become weaker and less dense, wrists, spines and hips are more likely to break. The spine starts to curve and there might be discomfort and pain.

Thinning of the bones is natural, but there is a lot you can do to avoid osteoporosis by staying healthy and strengthening your bones. Even if you do develop it, treatment can prevent further thinning of the bones.

What are the symptoms?

Osteoporosis develops gradually over many years, usually without any symptoms at all. Someone affected will probably not notice any problems until they are in 70’s. The first sign of it may be when the spine starts to curve, or when a slight fall or awkward movement causes a painful fracture.

Who gets it?

Osteoporosis can occur in both men and women at any time, but is more common from about 40 onwards. In women, thinning of the bones is more rapid around the time of- and just after- the menopause. This is because some women lose calcium more quickly as the level of oestrogen in their body drops.

You are more likely to develop osteoporosis if you:

• Have had an early menopause.

• Have been treated with long- term corticosteroids.

• Have a history of missed periods.

• Have already broken a bone after a minor bump or fall.

• Have a family history of osteoporosis.

• Have a history of heavy smoking or drinking, low calcium intake or immobility.

Can it be treated?

Hormone Replacement Therapy (HRT) can halt and prevent further bones loss.

How can I help myself?

Since osteoporosis actually starts long before you notice any symptoms, it makes sense to take action now to prevent or reduce the effects.

• Eat a healthy, balanced diet. Eating a varied and well- balanced diet is important for good health. This can be done by choosing a variety of foods from each of the five food groups: milk and dairy foods; meat, fish and alternatives; bread, other cereals and potatoes; fruit and vegetables; foods containing fat, foods containing sugar. For healthy bones, make sure your diet includes calcium- rich foods such as milk and dairy foods (cheese, yoghurt and so on), nuts, canned fish, and dark, leafy vegetables. Fat- reduced varieties are healthier.

• Make sure you get enough vitamin D. This is particularly important in winter. Vitamin D helps to activate the production of calcium and is found in fortified margarines, oily fish, eggs and milk. It is also made by your skin when you go out into sunlight.

• Stay physically active. This is extremely important in maintaining bone density, muscle strength and balance throughout life. It reduces the risk of fracture and osteoporosis in later life. Try walking, dancing, cycling, tennis, swimming or something similar that you enjoy.

• Avoid smoking and heavy drinking. They can make the condition worse.

Hormone replacement therapy (HRT).

Hormone replacement therapy (HRT) can help ease or prevent some of the uncomfortable symptoms of the menopause. It can also protect against osteoporosis and heart disease. Some women believe HRT has completely changed their lives for the better. Others feel that they do not need it, or that it’s ‘unnatural’.

You need accurate information about the nature of the treatment and its benefits and its drawbacks in order to decide if HRT is right for you.

What is hormone replacement therapy?

Before, during and after the menopause, your body produces less and less of the hormone oestrogen. HRT is designed to ‘top up’ the body’s natural supply of oestrogen. Progestogen is usually added to protect the lining of the womb.

Oestrogen is usually taken by mouth in tablet form, as a skin patch or skin gel, as a vaginal cream or ring to ease vaginal discomfort. Your doctor would be able to explain the different options.

What are the benefits?

HRT is prescribed to ease or prevent many of the uncomfortable symptoms associated with the menopause.

It can:

• Stop hot flushes and sweats.

• Restore the vagina’s elasticity and natural lubricant.

• Help you feel better in yourself.

HRT also protects against osteoporosis. It helps to prevent thinning of the bones in women after the menopause, especially when it is taken within a few years of the menopause when bone loss is most rapid.

HRT is particularly valuable for women who have had their ovaries removed before the menopause, as they are at an even higher risk of osteoporosis.

How long would I have to take it?

A course of treatment can last from around six months to two years, sometimes a little longer under supervision. Symptoms such as hot flushes and vaginal dryness should not return after the treatment stops.

What are the risks?

There may be a slightly risk of breast cancer when HRT is taken for 5-10 years or more.

Are there any side effects?

There might be some side effects, including the return of periods (withdrawal bleeds). If you are taking HRT and notice side effects, don’t stop taking the treatment- tell your doctor. There a many different doses and types of treatment, and if one kind of treatment does not work well for you, there should be other options.

Possible side effects include:

Oestrogen

• Breast tenderness and enlargement.

• Leg cramps.

• Bloating.

• Nausea.

• Headaches.

Progestogen

• Pain in the lower abdomen.

• Fluid retention, back pain.

• Depressed mood.

How do I know if HRT is right for me?

This is something you should consider carefully and discuss with your doctor. Find out all the information you can about HRT. You will need to weigh the benefits to yourself against the possible risks. Much will depend on your medical history, symptoms and state of health.

Medical Specialists

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Consultant Obstetrician and Gynaecologist

Dr. Madhu Shree Vijayakumar

Dr. Madhu Shree Vijayakumar, is an obstetrician and gynaecologist with about a decade experience in addressing women’s health problems from adolescence to post menopause.

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Consultant Psychiatrist

Dr. Vijayakumar D.R

Dr. Vijayakumar D.R is a senior psychiatrist with more than 22 years of experience in handling mental health issues in India, Australia and the United Kingdom.

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